Wiki Addended record

[ginger.penton@gmail.com]

If a medical record has an addendum, does it need to be signed by the physician? The report does indicate the addendum date/ time/ and person who modified the record along with what was modified. In this case the modification is the place of service.

Thank you,

Ginger Penton

 

[Heatherc7]

Hi Ginger,

An addedndum, can simply state, updated Dx to E11.40, and the providers name/date/time. However, a good EMR automatically time stamp. If it's not set up, you may want to contact the EMR IT to find out how to turn that feature on.

Hope that helps!